Integrative Manual Therapy For the Upper and Lower Extremities

EVALUATE Limitation of Motion: Elbow Supination TREATMENT Medial Epicondyle (MEP) Tender Point: high on medial epicondyle POSITION • Supine or sitting. • Ipsilateral elbow flexion with overpressure. • Ipsilateral wrist flexion with overpressure. • Ipsilateral forearm pronation to end of range. • Synergic Pattern Release®





CHAPTER 10 MYOFASCIAL RELEASE A 3-PLANAR FASCIAL FULCRUM APPROACH TO CORRECT SOFT TISSUE AND JOINT DYSFUNCTION WITH DEFACILITATED FASCIAL RELEASE This concept was developed at Regional Physi­ De-Facilitated Fascial Release can be implemented cal Therapy. The technique is invaluable to im­ from: (1) Strain and (aunterstrain Technique, prove arthrokinematics with a 3-planar Fascial Fulcrum Release (Weiselfish-Giammatteo) to ad­ and (2) Muscle Energy and 'Beyond' Technique dress capsular and ligamentous tension and in­ stability. Fascial Concepts The Process of De-Facilitated Fascial Release Tissues are the matrix of the body, composed of cellular elements and their derivatives. The cells Position the body for StrainlCounterstrain may be held together by the adhesions of their surface membranes, or by protoplasmic connec­ (use the techniques from Chapters 8 and 9). tions; they may be scattered throughout an in­ Maintain the position for 90 seconds (2 to tercellular ground substance containing tissue fluid, fibrous elements, and organic material. A 3 minutes for the neurologic patient). tissue is a collection of cellular and fibrous ele­ • Focus on all tissue tension changes, move­ ments in which one unique type of cell or fiber predominates. The four ptimary body tissues in­ ments, pulses, rhythms. clude: epithelial tissue for protection, secretion, • While there are changes occurring, maintain and absorption; muscular tissue for contraction; nervous tissue for irritability and conductivity; the Strain/Counterstrain position with pre­ connective tissue for support, nutrition, and cisely the same forces, not allowing any defense. physiologic movement to occur. • Continue to maintain this position until all The largest component of the human body, tissue tension changes have ceased connective tissue, forms a continuous, contigu­ completely. ous system throughout the body. The connective tissue system includes all the components of the The practitioner is maintaining a fixed point mesenchyme: ground substance, elastin, colla­ around which the tissue can unravel (Fascial gen, muscle, bone, cartilage, and adipose tissue. Fulcrum Release). The unwinding of the fascial The various components of connective tissue are tissue that occurs secondary to the continuation not distinct, but present many transitional of the Strain/Counterstrain technique will hap­ fotms. These components of connective tissue pen secondary to the de-facilitation of the spinal are characterized by large amounts of intercellu­ segments. This unwinding will not occur unless lar material. The consistency of the connective initiated with the StrainlCounterstrain. tissue is dependent upon the relative amount and proportion of collagenous and elastic fibers. Often significant improvements in arthro­ Some areas of the body have thin, delicate, retic­ kinematics occur after this approach, and pos­ ulum, and other areas present tough fibrous ture will reflect these changes. Mobility and ranges of motion will be increased. Ligamentous instability responds well to this approach. After several StrainlCounterstrain techniques, the tis­ sue is ready to respond in this manner. 101

102 ADVANCED mAIN AND CDUNmmAIN sheets. The connective tissue is a highly special­ bursal sacs ro minimize the affects of pressure ized and complex tissue. The connective tissue and friction in the body. Connective tissue cre­ contains and comprises blood vessels and lym­ ates restraining mechanisms in the form of phatic vessels in order ro implement the func­ bands, pulleys, and ligaments. It aids in promot­ tions of nutrition, defense, and repair. The cells ing circulation of veins and lymphatics by pro­ and fibers dispersed throughout the connective viding sheaths. It furnishes the sites for muscle tissue system are embedded in a matrix of semi­ arrachments. It forms spaces for storage of fat fluid gelatinous substance. Connective tissue can ro conserve body heat. It has fibroblastic activity be grouped as follows: in order ro repair tissue injury by forming scar tissue. Connective tissue contains hisrocytes, Conllective Tissue Proper which is a connective tissue cell that participates in phagocytic activity to defend against bacteria. • Loose connective tissue (areolar). This tis­ The connective tissue synthesizes antibodies to sue contains spaces of fluid, and is involved neutralize antigens by its plasma cells, which are in cellular metabolism. Intercellular sub­ another connective tissue cell. It contains tissue stances include: (a) collagenous or white fluids ro participate in tissue nutrition. fibers: collagen fibers are parallel fibers bound rogether in bundles giving it tensile Fascia is specialized connective tissue. Fascia strength; (b) elastic or yellow fibers: elastin envelops muscle fibers, and acts as a lubricant ro contributes ro the elasticity; (c) reticular permit freedom of movement of adjacent muscle fibers: the delicate collagenous fibers hmc­ groups. Tendons arc bundles of heavy collagen tion ro support cells. fibers running parallel ro one another. Tendons connect muscles ro bone and can sustain enor­ • Dense connective tissues. mous tension. Ligaments are similar to tendons, • Regular connective tissues: Tendon, Fibrous bur the collagen fibers are not arranged as regu­ larly and may contain some elastic fibers. Liga­ membranes, Lamellated connective tissue. ments usually connect bone to bone. Cartilage is a fibrous connective tissue with a firm matrix. Special Connective Tisslle The cells are called chondrocytes. Hyaline, fi­ brocartilage, and elastin are specific types of • Mucous cartilage. Muscle has often been considered a Elastin: fibers running singly, branching specialized form of connective tissue, the freely, and anasromosing with each other. smooth and voluntary striated muscles. Bone and cartilage have been considered modified • Reticular forms of collagen. Bone is harder connective tis­ • Adipose sue, in which large amounts of calcium comprise • Pigmented a solid matrix of fibrous connective tissue. Amorpholls Fascia is a rough connective tissue that spreads in a functional 3-dimensional web from • Ground the head ro the roe. Fascia gives the body form; • Cement if all other tissues and structures were removed from the body, the body would retain its shape. Cartilage This is because every muscle, bone, organ, Bone nerve, and vessel is wrapped in fascia. The fascia Blood and Lymph separates, supports, binds, connects, and de- Connective tissue has various functions. This system provides the supporting matrix for highly specialized organs and structures. It pro­ vides pathways for nerves, blood vessels, and lymphatic vessels, by organization of fascial planes. The connective tissue facilitates move­ ment berween rhe adjacent srructures. It forms

UPPER AND LOWER EXTREMITIES 103 fends everything. The fascia extends to form perironeum, and are attached ro various por­ muscular attachments, to support membranes, tions of the abdominal wall and form ligaments to provide intermuscular septa, to give visceral ro maintain the position of solid viscera. The ligamentous attachments, and to invest sheaths cervical visceral fascia extends from the base of for blood vessels and nerves. The connective tis­ the skull ro the mediastinum, forming compart­ sue found in the interstitial tissues of the viscera ments for the esophagus, the trachea, the carotid forms the membranes through which the os­ vessels, and providing support for the pharynx, moric processes of nutrition and elimination larynx, and thyroid gland. take place. The pressure and tissue tension pro­ vided by the fascia have a marked influence The connective tissue is comprised of colla­ upon the osmotic exchange of fluid. The fascia gen, elastin, and the polysaccharide gel com­ affects the delivery of the metabolites into the plex, the ground substance. Collagen is a filtering capillaries. The fascia affects the os­ protein of 3 polypeptide chains which provide motic balance which exists between the circula­ strength ro this fascial tissue. Elastin is a protein tory fluids and the tissue fluids, which preserves which is rubber-like and absorbs tensile forces. physiologic balance. Functionally, the fascia can Together, the elastin and collagen combine ro be separated into layers: the superficial fascia, form an elasrocollagenous complex. The poly­ which adheres to the undersurface of the skin saccharide gel fills a space between the fibers. and the deep fascia, which envelopes and sepa­ The major components are hyaluronic acid and rates muscles, surrounds and separates internal proteoglycans. Hyaluronic acid is viscous, and organs, and contributes to the contour and func­ provides lubrication for the collagen, elastin, tion of the body. and muscle fibers allowing for friction-free movement. Proteoglycans are peptide chains Specializations of the deep fascia include the which contribute ro the gel of the ground sub­ peritoneum, the pericardium, and the pleura. stance which is hydrophilic and thereby rich in Subserous fascia is the loose areolar tissue which water content. envelops the viscera. This fascia provides friction free movement between the organs. The deepest Monuol Theropy ond Fosciol/Myofosciol Dysfunction fascia is the Dura Mater. All these tissues are connected continuously and contiguously. Neuromusculoskeletal dysfunction causes pos­ tural dysfunction. Postural dysfunction pro­ The intercranial structures are connected duces fascial tensions. The traction produced by through the foramina at the base of the skull. postural dysfunction upon the sensory nerve ele­ Within the chest cavity, the pericardium extends ments within the connective tissue system may upwards to become continuous with the pre-tra­ produce pain. cheal layer of the deep cervical fascia, and below is attached to the diaphragm. The heart is sus­ As a manual practitioner develops the spe­ pended in the chest by the attachments of the cialized sense of touch necessary for diagnosis of pericardium and related fascia. The pericardium tissue disorders, differential diagnosis is facili­ is connected with the mediastinal pleura. The tated. Education of tactile senses can determine mediastinal fascia connects the bifurcation of if tissue is tense, relaxed, or altered due ro im­ the trachea, the descending aorta and the esoph­ balance of tissue chemistry. The development of agus. The abdominal fascia includes the mesen­ palpation skills is essential for diagnosing fascial tery, the omentum, and numerous ligaments dysfunction. which provide suppOrt for the abdominal viscera. The omentum consists of a fold of the Fascial dysfunction can contribute ro changes in health: local, regional, and rotaI body. Ligamentous tension alterations are

104 ADVANCED mAIN AND COUNmmAIN important In joint lesion pathology. Stretching emphasize the point that indirect techniques of ligaments can result in hypermobility of cause less body resistance and provide more ef­ joints. Dislocations of bone, whether mild with (ective and efficient results. imbalance of the articular surfaces, or severe, will result in tendon tension. This tendon ten­ Indirect Techniques sion is transmitted to muscle fibers which pro­ duces compensatory hypertonicity and muscle On 3 planes the tissues/joints are moved away contractions. from the barrier, into the direction of the most mobility. The tissues/joint are unloaded. A re­ Immobilization may result in fascial dys­ laxation in the tissue tension will result from the function. Research has provided evidence that treatment, and heat will be released from the long periods of immobilization produces muscle tissues. atrophy, joint stiffness, ulceration of joint carti­ lage, osteoarthritis, skin necrosis, infection, ten­ Tissue Release docutaneous adhesion, thrombophlebitis, and varying degrees of contracture. Research has The therapist monitors tissue tension during provided evidence that synovial fluid post im­ Manual Therapy techniques. When the tissue mobilization has excessive connective tissue de­ tension changes, softens and relaxes, this is a tis­ position in the joint and joint recesses. After a sue release. These releases occur during a treat­ time, the excessive fibrous connective tissue ment technique. deposits form mature scar and create intra­ articular adhesions. Post immobilization, matrix This decrease in tissue tension during Man­ changes have been reported in ligament, cap­ ual Therapy has been attributed to several fac­ sule, tendon, and fascia. Research has also pro­ tors. One factor is the decrease in gamma gain vided evidence that functional loading can cause and efferent gain from the central nervous sys­ regeneration of tendons. Enwemeka performed tem, resulting in a relaxation and elongation of research which showed that controlled passive muscle fibers. Another factor is the change of mobilization promotes gliding and accelerates elastic resistance to viscous compliance due to the rate of healing of tendons. With the mobi­ morphologic changes. There is an apparent re­ lization, reports of water loss, increased synthe­ laxation of these elastic fibers. Tissue tension re­ sis of new collagen, and an increase in the lease occurs simultaneously with a perception of cross-links between collagen fibers have been increased fluid throughout the tissues, and a presented. The excessive and abnormal cross­ sense of increased energy throughout those tis­ link formation between fibers contributes to sues treated. During the treatment technique, joint restriction. heat is emanated from those body tissues, there is a sensation of movement, filling of space, and Fascial Release Techniques can be often a therapeutic pulse. Direct or Indirect Technique. This therapeutic pulse occurs frequently Direct Techniques during Manual Therapy techniques. The ampli­ Move the tissues to the barrier on 3 planes. The tude or force of this therapeutic pulse increases tissues are loaded in the direction of the least during the treatment technique and subsides as mobility. A relaxation in the tissue tension will the correction of the neuromusculoskeletal tis­ result from the treatment, and heat will be re­ sue is completed. leased in the tissues. The author and colleagues Fascial Fulcrum Techniques There are two generic fulcrum fascial release techniques:

UPPER AND lDWER EXTREMITIES 105 • Soft Tissue Fulcrum Myofascial Release (cephalad/caudad or caudad/cephalad) was • Articular Fulcrum Fascial Release the mobility greatest, with least resistance. Move the hands in the \"indirect\" direction Applicatiol1 of ease. Keep hands in that new position. This technique can be performed mechanically 3. 2nd Plane: Now add, or \"stack\" the second with excellent results. Development of palparion skills will enhance these results. plane movements. Do not return the hands or the tissues to neutral. Move the tissues Soft Tissue Myofascial Release Technique under the anterior hand medially, while the posterior hand moves the tissue laterally. Soft Tissue Myofascial Release techniques can Rerurn the tissues to neutral, and compare be performed where positive myofascial map­ the ease of tissue mobility when the anterior ping, decreased fascial glide, static postural dys­ hand moves the tissue laterally while the function, and dynamic limitations in motion posterior hand moves the tissue medially. indicate positive findings of dysfunction. Consider: which directions (medial/lateral or lateral/medial) were the most mobile, the Example: Soft Tissue Myofascial Release of the Knee easiest, the least restricted. Rerurn the tis­ sues to that position. Maintain these direc­ Indication tions of forces on the tissues, as well as those forces from the 1st plane. Pain, postural dysfunction, limitations 111 knee motions 4. 3rd Plane: Now add, or \"stack\" the third Position plane. Do not return the tissues to neutral; they are displaced from neutral on 2 planes Supine. One hand of the therapist is underneath now. Move the tissues with the anterior the knee joint. The fingers are spread apart, con­ hand in a clockwise direction, while the tacting as much tissue and structure as possible. posterior hand moves the tissues in a coun­ The second hand of the therapist rests above the terclockwise direction. Then return the tis­ knee joint. The fingers are spread apart, contact­ sues to neutral on this plane; compare the ing as many tissues and structures as possible. opposite tissue distortion pattern. Move the tissues counterclockwise with the anterior Treatment hand, while the posterior hand moves the tissues clockwise. Compare the 2 different 3-Planar Fulcrum Myofascial Release Technique tissue distortion patterns (clockwise/coun­ to the Knee terclockwise or counterclockwise/clockwise): which was 1. COl1lpress the knee with both hands, the indirect pattern with the greatest mobil­ ity. Return the tissues in that direction of squeezing gently, imaging a soap bubble distortion. Now there are 3 directions of between the hands. Don't burst the soap forces from each hand onto the tissues; each bubble! Maintain the gentle compression. hand is displacing the tissues on 3 planes. 2. 1st Plane: The anterior hand moves cepha­ 5. The Fulcrum: Each hand exerted 4 different lad while the posterior hand moves caudad, directions of forces mechanically to distort distorting the soap bubble. The hands re­ the tissue between the hands. The directions rurn to neutral and reverse directions: the of force were: anterior hand moves the tissue caudad, while the posterior hand moves the tissue • compressIOn cephalad. Consider: which directions

106 ADVANCED mAIN AND CDUNmmAIN superior or inferior Example: Articular Fascial Release of the Knee Joint • medial or lateral • clockwise or counterclockwise (medial Indication rotation or lateral rotation) Localized postural dysfunction at the knee joint; Each hand will now maintain all four direc­ lateral shear of the proximal tibial head on the tions of forces, maintaining a fulcrum for distal femoral head. the tissue unwinding, throughout the dura­ tion of the technique. This fulcrum will Position create energy which will be transmitted into the body. Supine. One hand of the therapist grips the dis­ tal femur head; the second hand grips the proxi­ 6. Maintaining the Fulcrum: As the tissue un­ mal tibial head. Do lIot distract or approximate winds, and movement occurs in the body's the joint surfaces. internal environment, there is a temptation to move the hands and release the fulcrum. Treatmellt Resist the temptation. The therapist and patient may perceive heat, paresthesia, 3-Planar Fulcrum Articular Fascial Release anaesthesia, vibration, fatigue, electricity, Technique cold, perspiration, pain, circulatory changes, breathing changes, sympathetic 1. 1st Plane: The superior hand on the femur skin erythemia or blanching, and more. Do not release the fulcrum; ar the end of lifts the femoral head anterior, while the the technique the signs and symptoms will inferior hand on the tibia pulls the tibial subside. The technique is complete when all head posterior. Then return to neutral and movement, signs, symptoms, and percep­ reverse the directions. The superior hand tions have ceased. pushes the femur posterior, while the infe­ Result: Improved postural symmetry, decreased rior hand pushes the tibial head anterior. pain, increased knee movements. Compare: Which direction (anterior/poste­ rior or posterior/anterior) was the mOSt mobile. Return the joint surfaces to that position of greatest mobility. Maintain the position of the articular surfaces on this plane. 2. 2nd Plane: Now add, or \"stack\" the second plane movements. The superior hand hold­ ing the femoral head can push the femur lateral, while the inferior hand holding the tibia can push the tibial head medial. Then return to neutral and reverse the directions of the articular surfaces. The superior hand now pushes the femur medial, while the inferior hand pushes the tibia lateral. Com­ pare the directions (medial/lateral or lat­ eral/medial). Move the joint surfaces in the indirect directions of ease. Maintain the articular surfaces in this new po ition. 3. 3rd Plane: Now add, or \"stack\" the third plane movements. The superior hand grip-

UPPER AND LOWER EXTREMITIES 107 ping the femur can rotate the femoral head Example: Treatment of the Shoulder Girdle and externally, while the inferior hand gripping Clavipectorol Fascia with 3-Planar Fulcrum the tibia rotates the tibial surface internally. Myofascial Release Technique Then rerurn ro neutral, and reverse the di­ rections. The superior hand can push the 1. Compress the clavipecroral region with femoral head into internal rotation, while the inferior hand moves the tibia into exter­ both hands, squeezing gently, imaging a nal rotation. Compare the directions (exter­ soap bubble between the hands. Don't nal/internal rotations or internal/external burst the soap bubble! Maintain the gentle rotations). Move the articular surfaces on compression. this plane in the indirect direction of great­ est mobility, least resistance. Maintain the 2. 1st P/0/1e: The anterior hand moves cepha­ positions of the articular surfaces on this plane. lad while the posterior hand moves caudal, disrorting the soap bubble. The hands re­ 4. The Fulcrum: Each hand has exerted three turn ro neutral and reverse directions: the anterior hand moves the tissue caudal, different directions of mechanical forces ro while the posterior hand moves the tissue position the articular surfaces in opposite cephalad. Consider: which direction (cepha­ directions on 3 planes. Each hand will now lad/caudad or caudad/cephalad) was the maintain all 3 directions of forces, main­ mobility greatest, with least resistance. The taining a fulcrum for the unwinding tissue hands move the tissues in the \"indirect\" of the joint capsule and ligaments through­ direction of ease, the most mobile direction. out the duration of the technique. Keep hands in that new position, maintain· ing those directions of forces on the tissues. S. Maintaining the Fulcrum: As the tissue 3. 2nd l'Ialle: Now add, or \"stack\" the second unwinds, and sensations of extra-articular and intra-articular movement are perceived, plane movements. Do not return the hands there is a temptation ro move the hands and or the tissues ro neutral. Move the tissues release the fulcrum. Resist the temptation ro under the anterior hand medially, while the release the fulcrum. Maintain the fulcrum until all movement, all signs, all symproms and all perceptions have ceased. Result: Improved articular balance. Normal neutral balance of femoral head and tibial head; increased joint mobility; increased ranges of knee motions.

108 ADVANCED mAIN AND CDUNTERSTRAIN posterior hand moves the tissue laterally. energy which will be transmitted into the Return the tissues to neutral, and compare body. the ease of tissue mobility when the anterior hand moves the tissue laterally while the 6. Maintaining the Fulcrum: As the tissue un­ posterior hand moves the tissue medially. Consider: which directions (medial/lateral winds, and movement occurs in the body's or lateral/medial) were the most mobile, internal environment, there is a temptation the easiest, the least restricted. Return the to move the hands and release the fulcrum. tissues to that position. Maintain these Resist the temptation. The therapist and directions of forces on the tissues, as well patient may perceive heat, paresthesia, as those forces from the 1 st plane. anaesthesia, vibration, fatigue, electricity, cold, perspiration, pain, circulatory 4. 3rd Plane: Now add, or \"stack\" the third changes, breathing changes, sympathetic skin erythemia or blanching, and more. plane. Do nOt return the tissues to neutral; Do not release the fulcrum; at the end of they are displaced from neutral on 2 planes the technique the signs and symptoms will now. Move the tissues with the anterior subside. The technique is complete when all hand in a clockwise direction, while the movement, signs, symptoms, and percep­ posterior hand moves the tissues in a coun­ tions have ceased. terclockwise direction. Then return the tis­ Result: Improved postural symmetry sues to neutral on this plane; compare the (decreased protraction) and increased hori­ opposite tissue distortion pattern. Move the zontal abduction. tissues counterclockwise with the anterior hand, while the posterior hand moves the tissues clockwise. Compare the 2 different tissue distortion patterns (clockwise/coun­ terclockwise or counterclockwise/clock­ wise); which was the indirect pattern with the greatest mobility? Return the tissues in that direction of distortion. Now there are 3 directions of forces from each hand onto the tissues; each hand is displacing the tis­ sues on 3 planes. 5. The Fulcrum: Each hand exerted 4 different directions of forces mechanically to distort the tissue between the hands. The directions of force were: compreSSIOn • superiorlinferior • medial/lateral clockwise/counterclockwise (medial rotation or lateral rotation) Each hand will now maintain all four direc­ tions of force, maintaining a fulcrum for the tissue unwinding, throughout the duration of the technique. This fulcrum will create

UPPER AND LOWER EXTREMITIES 109 Example: Treatment of the Glenohumeral the joint surfaces to neutral and reverse the Joint with Articular Fascial Release directions of the articular surfaces. The su­ perior hand now pushes the glenoid fossa Indication posteriorly, while the inferior hand pushes the humeral head anteriorly. Compare the Static postural dysfunction: for example, directions (anterior/posterior or anterior shear of the humeral head in the posterior/anterior). Move the joint surfaces glenoid fossa. in the indirect directions of ease. Maintain Dynamic postural dysfunction: limitation in the articular surfaces in this new position. some end ranges of shoulder motions, with Now each articular surface is displaced in hypomobility of accessory movements evi­ different directions. dent on mobility testing. 3. 3rd Plane: Now add, or \"stack\" the third Positioll plane movements. The superior hand grip­ Supine or sIttIng. One hand of the therapist ping the shoulder girdle can rOtate the gle­ grips the shoulder girdle to control the position noid fossa externally, while the inferior of the glenoid fossa. The second hand grips the hand gripping the upper arm rotates the upper arm to control the position of the humeral humeral head internally. Then return the joint surfaces to neutral, and reverse the head. Do not distract or approximate the joillt directions. The superior hand can push the surfaces. glenoid fossa into internal rotation, while the inferior hand moves the humeral head Treatmellt into external rotation. Compare the direc­ 3-Plallar Fulcrum ArtiClilar Fascial Release tions (external/internal rotations or inter­ Technique nal/external rotations). Move the articular I. 1st Plalle: The superior hand on the shoul­ sutfaces on this plane in the indirect direc­ tion of greatest mobility, least resistance. der girdle lifts the glenoid fossa cephalad, Maintain the positions of the articular sur­ while the inferior hand on the upper arm faces on this plane. Now the 3 directions of pulls the humeral head caudad. Then return forces exerted to displace each articular the joint surfaces to neutral, and reverse the surface is maintained. directions of the articular surfaces. The su­ perior hand pushes the glenoid fossa cau­ 4. The Fulcrum: Each hand has exerted three dad, while the inferior hand pushes the humeral had cephalad. Compare: Which different directions of forces to mechani­ direction (cephalad/caudad or caudad/ cally move and position the articular sur­ cephalad) was the most mobile, the least faces in opposite directions on 3 planes. restricted and the least inhibited? Return Each hand will now maintain all 3 direc­ the joint surfaces to that position of great­ tions of forces, maintaining a fulcrum for est mobility. Maintain the position of the the unwinding tissue of the joint capsule articular surfaces on this plane. and ligaments throughout the duration of the technique. 2. 2nd Plane: Now add, or \"stack\" the S. Maintaining the Fulcrum: As the tissue second plane movements. The superior hand holding the shoulder girdle can push unwinds, and sensations of extra-articular the glenoid fossa anteriorly, while the infe­ and intra-articular movement are perceived, rior hand holding the upper arm can push there is a temptation to move the hands and the humeral head posteriorly. Then return release the fulcrum. Resist the temptation to

110 ADVANCED IIRAIN AND CDUNTERIIRAIN release the fulcrum. Maintain the fulcrum until all movement, all signs, all symptoms and all perceptions have ceased. Result: Improved articular balance. Normal neutral balance of humeral head within the glenoid fossa; increased joint mobility; in­ creased ranges of shoulder motions.

CHAPTER 11 TENDON RElEASE THERAPY© FOR TREATMENT OF TENDON TISSUE TENSION WITH ADVANCED STRAIN AND COUNTERSTRAIN The tendons are apparently innervated by the tendon. There may remain {ascial restrictions o{ autonomic nervous system, because function­ the tendon, which may still require {ascial re­ ally, they respond in a similar manner to smooth lease. The tendon responds well to De{acilitated muscles. There is a passive contractile function, Fascial Release. that is required for the stretch reflex of the pro­ prioceptors, such as the Golgi Apparatus. The Tendon Release Therapy© contractile tissues are longitudinal along the length of the tendon. When there is hypertonic­ Step 1 ity of a tendon, it presents as a rigidity of the Place the index finger (or the index finger plus tendon. There is a reduced capacity of elonga­ the third finger) pad of the distal phalanx of the tion and contraction of the tendon fibers. caudal hand over the place of insertion of the in­ ferior end of the tendon. Duration of treatment of tendons with Ad­ vanced Strain and Counterstrain is 1 minute be­ Step 2 cause all innervated muscles require 1 minute Place the index finger (or the index finger plus for release of hypertonicity, as compared to 90 third finger) pad of the distal phalanx of the su­ seconds release for voluntary nervous system in­ perior hand over the musculotendinous inter­ nervated muscles. This approach was developed face of the muscleltendon, at the superior aspect by Giammatteo and Weiselfish-Giammatteo, in­ of the tendon. corporated into their text \"Advanced Strain and Counterstrain Technique.\" The process of Defa­ Step 3 cilitated Fascial Release works well with tendon Push on the tendon tissue with both hands (fin­ hypertonicity. gers) with 1 lb. force perpendicular onto the bone. Tendons of voluntary striated muscles are treated in a relatively simple manner with Ad­ Step 4 vanced Strain and Counterstrain Technique, Then compress the superior aspects and inferior with excellent results. The distal and proximal aspects of the tendon together with 1 lb. force, ends o{ the tendon are pressed against the bone, bringing the proximal and distal ends of the ten­ pressing perpendicular through the fiber onto don closer togerher. the bone. This pressure is at the insertion o{ the distal aspect o{ the tendon, where it inserts into Step 5 the bone, and at the proximal aspect where the muscle fibers integrate with the tendon fibers. Maintain these (4) compressive forces for one Maintaining this direct pressure o{ approxi­ mately 1 pound {orce, the distal and proximal minute for the Advanced Strain and Counter­ ends o{ the tendon are compressed. This com­ strain. pression is along the longitudinal length o{ the tendon fibers. The compression is maintained Step 6 {or 1 minute {or release o{ hypertonicity o{ the If fascial unwinding is perceived, maintain the 111

112 ADVANCED ITRAIN AND CDUNlEIlTIAIN (4) compressive forces during a Defacilitated Sequence of Strain and (ounterstrain for Tendons Fascial Release. 1. Muscle Energy and 'Beyond' Technique for extremity joints. Indications for Tendon Release Therapy 2. Strain and Counterstrain for the muscle There are essentially no contra-indication for (of the involved tendon). Tendon Release Therapy when performed in this manner, unless there is a total rupture of the ten­ 3. DeFacilitated Fascial Release for the muscle don. When there is a total rupture of the tendon, (of the involved tendon). the technique will not be effective. 4. Tendon Release Therapy (Advanced train If there is a tear or rupture of the tendon, but there is a correction performed (surgical), and Counterstrain). the technique can be performed. Although not 5. DeFacilitated Fascial Release for the 100% effective, the technique will give some re­ sults in decreased hypertonicity and rigidity of tendon. the tendon if the Tendon Release Therapy is per­ 6. Myofascial Release (3-Planar Fascial formed immediately after surgery. There will be a facilitated healing of the tendinous injury. Fulcrum) Tendon Technique. Tendon Release Therapy is best performed Insertion Muscu�tendenous after Strain and Counterstrain is performed to Jundion the muscle of the tendon. Often there is no re­ maining hypertonicity of the muscle, only of the 01 tile tendon. In that case, Tendon Release Therapy AchiIIM Tendon can be performed without Strain and Counter­ strain to the muscle. figure 17. To perform Tendon R�... lheropy\", pres. on Ihe mlJS(ulo-t.ndinous iunction ond on tile insertion 01 After Tendon Release Therapy is performed, the A,hilles Tendon. Then shorten lhe libe�. there may be some residual fascial dysfunction of the connective tissue of the tendon. This oc­ curs most often when there are tears and scar­ ring of the tendon. After the Tendon Release Therapy, a 3-Planar Fascial Fulcrum Release Technique (Myofascial Release, Weiselfish-Gi­ ammarreo) can be performed for optimal re­ sults. The Advanced Strain and Counterstrain for the tendon (Tendon Release Therapy) affects the hypertonicity of the tendon, resulting in a softening of the tendon and a decrease in the rigid presentation of that tendon. When Defacil­ itated Fascial Release is performed immediately after the Tendon Release T herapy, often the fas­ cial dysfunction is corrected. When the scarring of the tendon (the fibrosis) is severe, there is often a need to perform the fascial release after the Tendon Release Therapy.

UPPER AND LOWER EXTREMITIES 113 Example: Achilles Tendon Indications For Tendon Release Therapy© Tender Point Typical Tendons which respond well with At the insertion of the Achilles tendon Tendon Release Therapyo: Position Prone. A small towel roll is placed under the • Achilles Tendon ankle, or the foot is off the edge of the bed, so • Medial and Lateral Hamstrings that the foot and ankle are not in forced plantar Aexion. Tendons Treatment • Quadriceps Tendon Place the index finger (or index finger plus the • Tibialis Anterior Tendon third finger) pad of the distal phalanx of the • Tibialis Posterior Tendon caudal hand over the place of insertion of the • Extensor Tendons of the Foot and Toes achilles tendon at the calcaneus. Place the index • Flexor Tendons of the Foot and Toes finger (or index finger plus third finger) pad of the distal phalanx of the superior hand over the • Abductor Hallucis musculotendinous interface of the gastrocne­ mius muscle with the achilles tendon, at the su­ • Adductor Tendons of the Hip perior aspect of the tendon. Push the tissue with • Rotator Cuff Tendons: Supraspinatus, a j lb. force perpendicular into the tibia. Then compress the superior aspect and inferior aspect Infraspinatus, Subscapularis of the tendon together with about a 1 lb. force, • Latissimus Dorsi bringing the 2 ends of the tendon closer to­ • Biceps Tendons (Short Head and Long gether. Maintain these compressive forces. Head) Figure 18. Tendon Releose Theropf for Ihe Achilles Tendon. Step 1: Compress • Trieeps Tendon A. and B. po�erior to onterior. Step 2: Shorten the lenglh 01 the tendon (e. and D.I. Maintain lor 90 seconds. • Coracobrachialis Tendon • Brachioradialis Tendon • Wrist Flexor Tendons • Wrist Extensor Tendons • Finger Flexor Tendons • Finger Extensor Tendons • Abductor Pollicis Tendon • Flexor Pollicis Tendon Common disorders which respond well to Tendon Release Therapyo: • Tendinitis • Hypertonicity (protective muscle spasm and spasticity) • Muscular Dystrophies • Hypotonias • Fibromyalgias • Tenosynovitis • Tears and ruptures of tendons • De Quervain-like syndromes • Hallux Valgus-like syndromes • Tendon Calcifications, such as calcifica­ tion of supraspinatus tendon and bicip­ ital tendon calcification

(HAPTER 12 LIGAMENTS: A TENSILE FORCE GUIDANCE SYSTEM TREATMENT WITH LIGAMENT FIBER THERAPY© The body has a system of ligaments which re­ both ligaments will access the lines of tension, sponds with tensionlforce that is partially due to and will alleviate the compromise of the line of the energies within the intra-articular space. tension between these two ligaments. The result Those energies which are within the intra-artic­ will be improved direction of motion from the ular space are particle and wave presentations body part guided by rhis line of tension, which that can be defined in quantum physics terms. probably responds to electrophysiologic internal These energies present 3-dimensional forces that signals and electromagnetic external forces. affect the tension of the ligaments and these lig­ aments react to this tension with a force that is The horizontal force of the ligament is more longitudinal as well as horizontal. difficult to address. Within the ligaments are horizontal forces that are the coordinating Ligaments are connective tissue that have forces of that body part during action and elastin, collagen, ground substance, as well as movement. The horizontal force of the ligament cells and other crystallized entities. The elastin coordinates the neighboring body parts that the and collagen respond in manners similar to the ligament is attached to, so that the body parts binding/supporting functions of fascial tissues which are attached will move in better relation­ such as the iliotibial band. The crystallized cells ship, one with the othet. In order to access this are apparently similar to the cells found in bone horizontal force within the ligament for im­ which have an electrophysiologic and electro­ proved coordination, there is a technique that magnetic component which can respond for can induce wave-like formation of the force. guidance. The function of the longitudinal force of ligaments is direction. The function of the If the hand is placed on the ligament while horizontal force of ligaments is coordination the joint is moving, the hand can respond to this which affects balance. horizontal force with intention to align this wave-like force in a horizontal manner. This There are lines of tension within rhe body technique can be performed during sagittal from ligament to ligament. Essentially all liga­ plane movements (flexion and extension), dut­ ments in the body have lines of tension with ing coronal plane movements (abduction and other ligaments. These lines of tension are the adduction, right and left sidebending), and energy waves which direct body parts duting ac­ transverse plane movements (external and inter­ tion, and which coordinate body parts during nal rotation). The hand rests on the ligament activity and movement. These lines of tension aligned in a horizontal manner in order to ad­ can be accessed by stretching ligaments. Each dress the horizontal force within the ligament. ligament is pulled in a longitudinal manner like From inner through outer range of each motion a string; this string is between the twO ligaments on each plane, this horizontal force can be that are being pulled in that longitudinal man­ aligned. ner. Direct longitudinal stretch with 2 ligaments at the same time will access this line of tension. If there is a biomechanical problem within In conditions of dysfunction, the line of tension the joint affecting the 3-planar presentation of may be compromised. A longitudinal stretch on the energy within that joint in the intra-articular space, it may be premature to work on the Iiga- 114

UPPER ANO LOWER EXTREMITIES 115 ment, especially in a horizontal alignment of Use Ligament Fiber TherapyO after Strain forces. The longitudinal traction of the liga­ and Counterstrain Technique is performed ments to address the line of tension to improve to the muscles surrounding the treated joint direction of that body part can often be ad­ dressed while addressing biomechanical dys­ (Chapters 8 and 9). function of the intra-articular space with Muscle Energy and 'Beyond' Technique. The horizontal • Then perform a 3-planar Soft Tissue force is less able to be corrected until there is a Myofascial Release technique at the joint correction of biomechanical problems. (Chapter 10). The movement for correction of the hor­ izontal force can be in a weight bearing or • Then perform a 3-planar Articular Fascial non-weight bearing manner. The longitudinal traction on the ligament ro access the line of Release technique at the joint (Chapter 10). tension and correct direction of the body part is best performed in a non-weight bearing manner. • Then perform Ligament Fiber Therapyo. When to use ligament Fiber Therapy ligament Fiber Therapy© (lFT) The horizontal fibers of the ligaments are Ligament Fiber TherapyO was developed by Weiselfish-Giammatteo to restore proliferation treated with a direct approach after therapy is of ligament activity. There are two phases to Ligament Fiber Therapy: performed, to treat local fascial restrictions. Usually, there is a need to perform a Soft Tissue Phase One: Myofascial Release technique, the 3-planar fas­ Horizontal Fiber TherapyO (HFT) cial fulcrum technique, at the joint (See Soft Tis­ • Phase Two: Longitudinal Fiber TherapyO (LFT) sue Myofascial Release Technique, Chapter 10). Horizontal Fiber TherapyO is usually per­ formed before Longitudinal Fiber TherapyO, in This technique is followed by an Articular Fas­ order to restore coordination of the joint, i.e., cial Release technique, the 3-planar fascial ful­ the co-joined activity of the two articular sur­ crum technique, to the joint (See example: faces of the joint so that each joint surface is Articular Fascial Release of Knee Joint, Chapter working correctly relative to the neighboring joint surface. 10). There are more specialized Myofascial Re­ Horizontal Fiber Therapy© lease Techniques which are not presented in this book, for example: Place the thenar or hypothenar eminence over the ligament. Place direct pressure in a perpen­ Ligament releases (Myofascial Release, Wei­ dicular direction onto the ligament. Rotate the selfish-Giammarreo) can be performed with fibers of the ligament in a clockwise and a coun­ the 3-planar fascial fulcrum approach to the terclockwise direction. Determine which direc­ ligaments surrounding the joint; tion, clockwise or counterclockwise, is more • Collateral ligament techniques (Myofascial restricted. Maintaining rhe direct perpendicular Release, Weiselfish-Giammarreo) are often pressure, rotate the ligament fibers in the re­ appropriate. stricted direction, to the end of amplitude with­ This protocol of Myofascial Release is often out overpressure. Then torque the ligament in a sufficient for mild and moderate joint pain sagittal plane, i.e., flexion and extension of the and disability. When there are further problems fibers. Stack this component, i.e., flex or extend with the joint, Ligament Fiber TherapyO can be (torque) the ligament in the sagittal plane direc­ implemented. tion which is more restricted. When these forces

1 16 ADVANCED STRAIN AND CDUNmSTRAIN of direct pressure plus rotation plus torque are Horizontal Fiber Release\": one inch lateral to applied together, stretch the ligament fibers to the umbilicus and two inches caudal. achieve separation of the horizontal fibers. There will be a \"Release\" of the tissues, a Introducing Synchronizers@> change in tissue tension. Maintain the pressure and contact of both hands until the end of the Synchronizers are reflex points. Use these reflex \"Release\" when changes are no longer occur­ points to attain improved results. Do a tech­ ring in tissue tension. nique, for example Ligament Fiber Therapy\". Try to perform the technique with one hand, longitudinal Fiber Therapy© (lFT) contact the reflex point with the second hand. Synchronizers\" were discovered by Lowen and Longitudinal Fiber Therapy\" is different from Weiselfish-Giammatteo, presented in courses of Horizontal Fiber Therapy\". This is apparently Biologic Analogs, presented by Therapeutic because the longitudinal fibers of the ligaments Horizons, which is a continuing education insti­ are a \"System\" of ligamentous fibers, which tute for advanced studies in manual therapy. contract and relax together, which respond to all changes in pressure and motion anywhere in the Synchronizer@> for Horizontal Fiber Therapy@> body as a \"Functional Unit.\" The longitudinal fibers require a total body approach to therapy. The synchronizer (a reflex point) for the hori­ These fibers are significant for many reasons. zontal fiber normalization is situated 1 inch lat­ eral to the umbilicus, then 2 inches caudal. Significance of longitudinal ligamenf Fibers How to use the Synchronizer© for The Ligament System appears to be a \"Guid­ Horizontal Fiber Therapy© ance System\" of the person. This means several important items: Step 1 Place one hand on the ligament, stacking all • The longitudinal ligaments perform the components for HFT\". \"awareness function\" for the distal bone of attachment: Is the distal bone moving Step 2 in the correct direction according to brain Direct pressure OntO the ligament. function? Step 3 • The longitudinal ligaments perform the Rotation clockwise or counterclockwise, in the \"awareness function\" of the distal bone of direction of resistance. attachment: Is the distal bone moving in the correct direction, according to the proximal Step 4 bone of attachment? Torque the ligament, i.e., flex or extend the liga­ The longitudinal ligaments perform the ment fibers in a sagittal plane, in the direction of \"awareness function\" of both the proximal resistance. and the distal bones of attachment: Is the person moving his/her body in accordance Step 5 with higher consciousness? Is he/she \"mov­ Place the second hand on the Synchronizer\" for ing\"on his/her Path? This aspect of the function of the longitudinal ligaments is presented at other educational forums, and will not be elaborated on in this text. This question of \"ligament awareness\" does

UPPER AND LOWER EXTREMITIES 1 17 appear ro be significant whenever there is Step 6 joint dysfunction affecting multiple joints: • Maintain the longitudinal traction on the \"[s the person 'being' in this life according ligament (inferior or superior). ro his/her unique Path?\" • Plus maintain the longitudinal distraction on the distal bone of attachment. Longitudinal Fiber TherapyC Plus maintain the 3-planar Articular Fascial Treatment of longitudinal fibers of ligaments is a Release of the distal bony articular surface. two phase therapy. Phase One requires assess­ ment and treatment of the individual ligament Step 7 involved. Phase Two requires a rotaI body approach. Maintain Step Six until a complete \"Release\" is attained. longitudinal Fiber Therapy�, Phase One Phase Two: longitudinal Fiber Therapy� (l�) Step 1 for the \"Guidance System\" Place a hand over the ligament. Longitudinal Fiber TherapyC is modified in this Step 2 text. LfTC approach will be facilitated with Assess: Place longitudinal traction on the liga­ Myofascial Mappingc. When Myofascial Map­ ment in a superior and an inferior direction (i.e., pingC is positive on a coronal and/or sagittal longitudinal stretch). Assess the resistance of: plane, L� can be modified for greater results. Myofascial Mapping\" was developed by Wei­ (1) inferior traction, and (2) superior traction. selfish-Giammatteo, and is a differential diag­ nostic technique which localizes areas of Step 3 neuromusculoskeletal dysfunction, and is taught Place longitudinal traction on the ligament in at courses presented by Dialogues in Contempo­ rary Rehabilitation. the direction of greater resistance: (1) inferior, or Longitudinal Fiber TherapyC for the Guid­ (2) superior. ance System requires the skill Local Listening, which was developed by jean Pierre Barral, Step 4 D.O., a French Osteopathic physician, inter­ Then place longitudinal traction (distraction) on nationally recognized for his manual therapy the distal bone of ligament attachment close ro approach, Visceral Manipulation. Visceral Ma­ the articular surface. nipulation courses are taught in North America under the direction of Frank Lowen. Local Lis­ Step 5 tening is a differential diagnostic technique for Then, move the articular surface of the ligament finding relationships and patterns of dysfunc­ attachment which is now distracted in a longitu­ tion. dinal manner (the distal bone of attachment), in a 3-planar articular fascial release. The Articular longitudinal Fiber Therapy©, Phase Two Fascial Release is a 3-planar fascial fulcrum ap­ proach developed by Weiselfish-Giammatteo, Step 1 presented in Chapter 10 of this text. Local Listen from the ligament in dysfunction.

1 18 ADVANCED STRAIN AND CDUNTERSTRAIN Step 2 ligaments, until all tissue tension changes during Local Listening is performed from the ligament the \"Release\" subsides. of the dysfunctional joint to other ligaments in the body. Often it is sufficient to scan the ex­ Step 7 tremity, if the ligament in dysfunction is in an Perform Neurofascial Processc among all of the extremity joint. If the ligament in dysfunction is ligaments of the body which are related in a sim­ in the spine, often it is sufficient to scan the ilar pattern, evident with Local Listening. spine. If the thorax and rib cage is the seat of the ligament in dysfunction, it may often be suffi­ Introducing Synchronizersc cient to scan the total thorax and rib cage. Synchronizers are reflex points. Use these reflex Step 3 points to attain improved results. Do the tech­ nique, for example Ligament Fiber Therapyo. When coronal and/or sagittal plane Myofascial Try to perform the technique with one hand, Mappingc is positive at the ligament of dysfunc­ contact the reflex point with the second hand. tion, and when multiple ligaments are involved, it is necessary to scan the total body with Local Synchronizer@ for Longitudinal Fiber Therapy<C> Listening. When Myofascial Mappingc is posi­ for the Guidance System tive on a transverse plane only at the ligament of dysfunction, it may not be necessary to scan the The SYl1chrol1izero for Longitudinal Fiber Ther­ total body. apyc for the Guidance System is located at the following place: three inches caudal to the fora­ Step 4 men magnum, from that point, one inch lateral. One hand contacts the ligament in dysfunction. How to use the Synchronizero for Longitu­ The second hand contacts the ligament/liga­ dinal Fiber TherapyO for the guidance system: It ments of positive Local Listening, one ligament is difficult to maintain all of the steps above for at a time. Longitudinal Fiber TherapyO for the Guidance system and at the same time to maintain hand Step 5 contact on the Synchronizero. The client's hand can be used for contact, or the hand of another Inhibitory Balance Testing (Chauffour, Mechan­ (for example, an aide). ical Link) can be performed among the liga­ ments which are Local Listening positive, in Ligament Fiber TherapyC can be performed order to discover the primary dominant liga­ after other techniques are utilized to restore ment/ligaments. Inhibitory Balance Testing was joint mobility, articular balance, and vertical di­ developed by Paul Chauffour in order to ascer­ mension of the intra-articular joint space. tain which dysfunction of the body overrides other dysfunctions. Treatment of Peripheral Joint Dysfunction: a Protocol Step 6 Assessment Perform Neurofascial Processc with hand con­ Evaluation of the client's objective findings is tact on both ligaments. Neurofascial Processo required prior to therapy. Assessment may was developed by Weiselfish-Giammatteo for include: treatment of pain and disability. W hen this tech­ nique is not familiar to the therapist, simply Posture: sagittal plane, coronal plane, trans­ maintain contact with both hands on the rwo verse plane of the spine.

UPPER AND LOWER EXTREMITIES 119 • Posture: sagittal plane, coronal plane, trans­ A Treatment Sequence for Joint Dysfun(tion verse plane of the extremities. Neurologic testing, including dermarome, Step 1 myotome, and scleratome which is appro­ Muscle Energy and 'Beyond' Technique for the priate for the pain and/or disability mani­ dysfunctional joint/joints. It is often preferable fested by the client. to treat the whole extremity/extremities when there is decreased vertical dimension of only one • Functional capacity testing for functional of the intra-articular spaces. impairments. Step 2 • Joint mobility testing of all appropriate Strain and Counterstrain for the Lower Quad­ joints. rant and/or Upper Quadrant with Synergic Pat­ tern Release\". • Ranges of motion of spine and extremity joints. Step 3 Soft Tissue Myofascial Release: Treat the total • Myofascial Mapping (Weiselfish-Giammat­ extremity where the joint dysfunction is present. teo). Step 4 • Local Listening (Barral). Articular Fascial Release of the dysfunctional Inhibitory Balance Testing (Chauffour). joint/joints. Therapy for peripheral joints of the arms Step 5 and legs is almost always appropriate after spine Specialized Fascial Release Techniques (Myofas­ has been assessed, alld oftell after pelvis, cial Release, Weiselfish-Giammatteo with Dia­ sacrum, spille alld rib cage have beell treated. logues in Contemporary Rehabilitation), for The biomechanical function of the peripheral example: scar releases, muscle belly releases. joints is dependent on the biomechanical func­ tion of the pelvis, sacrum and spine. It is highly Step 6 recommended that pelvis and sacrum joints are Ligament Fiber Therapy\": Horizontal Fiber tteated for biomechanical dysfunction before Therapy\": Phase One. Phase Two. other joints are treated, unless treatment is in­ hibited for some reason. Muscle Energy and 'Be­ Step 7 yond' Technique for the pelvis, sacrum and Ligament Fiber Therapy\": Longitudinal Fiber spine is suggested as exceptional intervention to Therapy\". Phase One. attain structural integrity of pelvis, sacrum and sp1l1e. Step 8 Ligament Fiber Therapy\": Longitudinal Fiber Therapy\" for the Guidance SystemC

CHAPTER 13 PROCEDURES AND PROTOCOLS TO CORRECT UPPER AND LOWER EXTREMITY DYSFUNCTION WITH INTEGRATIVE MANUAL THERAPY Treatment of Peripheral Joint Dysfunction: a Protocol A Treatment Sequence for Joint Dysfunction Assessment Step 1 Muscle Energy and 'Beyond' Technique for the Evaluation of the client's objective findings is dysfunctional joint/joints. It is often preferable required prior ro therapy. Assessment may to treat the whole extremity/extremities when include: there is decreased vertical dimension of only one of the intra-articular spaces. (Chapter 3 and • Posture: sagittal plane, coronal plane, trans­ Chapter 4) verse plane of the spine. Posture: sagittal plane, coronal plane, trans­ Step 2 verse plane of the extremities. Strain and Counterstrain for the Lower Quad­ Neurologic testing, including dermarome, rant and/or Upper Quadrant with Synergic Pat­ myorome, and scleratome which is appro­ tern Releaseo. (Chapter 8 and Chapter 9) priate for the pain and/or disability mani­ fested by the client. Step 3 Soft Tissue Myofascial Release: Treat the total • Functional capacity testing for functional extremity where the joint dysfunction is present. impairments. (Chapter 10) • Joint mobility testing of all appropriate Step 4 joints. Articular Fascial Release of the dysfunctional joint/joints. (Chapter 10) • Ranges of motion of spine and extremity joinrs. Step 5 Specialized Fascial Release Techniques (Myofas­ • Myofascial MappingO (Weiselfish­ ciaI Release, Weiselfish-Giammatteo with Dia­ Giammatteo). logues in Contemporary Rehabilitation), for example: scar releases, muscle belly releases. • Local Listening (Barral). (Not presented in this book) • Inhibitory Balance Testing (Chauffour). Step 6 Therapy for peripheral ;oints of the arms Tendon Release T herapy of the Tendons Sur­ and legs is almost always appropriate after spine rounding the Joint. (Chapter 11) has been assessed. Treat the pelvis, sacrum, spine and rib cage first. The biomechanical func­ Step 7 tion of the peripheral joints is dependent on the Ligament Fiber T herapyo: Horizontal Fiber biomechanical function of the pelvis, sacrum Therapyo: Phase One. Phase Two. (Chapter 12) and spine. It is highly recommended that pelvis and sacrum joints are treated for biomechanical dysfunction before other joints are treated, unless treatment is inhibited for some reason. Muscle Energy and 'Beyond' Technique for the pelvis, sacrum and spine is suggested as excep­ tional intervention to attain structural integrity of pelvis, acrum and spine. 120

UPPER AND LOWER EXTREMITIEI 12 1 Step 8 3. Protective Muscle Spasm: Strain and Coun­ terstrain: Iliacus; Medial Hamstrings; Ante­ Ligament Fiber Therapyo: Longitudinal Fiber rior 5th Lumbar; Abductors; Adductors Therapyo: Phase One. (Chaprer 1 2) ('without overpressure); Gastrocnemius; Quadriceps. Step 9 4. Repeat #3. Ligament Fiber Therapyo: Longitudinal Fiber 5. Articular Fascial Release: Pelvic joints; TherapyO for the Guidance Systemo. (Chapter 12) Knee joint. 6. Tendon Release T herapyO for Bilateral Total Hip Replacement Lower Extremity joints-Hold for DeFacili­ Evaluation tated Fascial Release. • Neurologic and Gait 7. Restore Ankle Dorsiflexion: Mobilize Sub­ Ranges of Physiologic Motion: talar and Tibiotalar joints (Do not place Lumbosacral Region, Hip, Knee, Ankle forces on hip). Mobility Testing of Accessory Movements: 8. Ligament Fiber TherapyO for Bilateral Knee joint Lower Extremity joints. • Manual Muscle Testing 9. Orthotics and strengthening. • Protective Muscle Spasm (Muscle Barriers): Lumbar Flexors; Iliacus; Adductors; Abduc­ Total Knee Replacement tors; Medial Hamstrings; Quadriceps; Gas­ trocnemius Evaluation Myofascial Testing: Pelvic diaphragm; Hip; Thigh; Knee • Neurologic and Gait Foot Posture • Ranges of Physiologic Motion: Treatment Lumbosacral Region, Hip, Knee, 1. Acute Stage (before 10 days post-op) Ankle Myofascial Release: • Mobility Testing of Accessory Move­ ments: Hip joint • Soft Tissue Myofascial Release: Trans­ • Manual Muscle Testing verse Diaphragms (all) • Protective Muscle Spasm (Muscle Soft Tissue Myofascial Release: Knee Barriers): Lumbar Flexors; lIiacus; Adductors; Abductors; Medial Ham­ • Muscle Energy Technique and 'Beyond' strings; Quadriceps; Gastrocnemius for Bilateral Lower Extremity joints Myofascial Testing: Pelvic diaphragm; Hip; Thigh; Knee; Ankle 2. Chronic Stage (any time after 10 days Foot Posture post-op) Treatment Myofascial Release: 1. Acute Stage (before 10 days post-op) • Soft Tissue Myofascial Release: Trans- Myofascial Release: verse Diaphragms • Soft Tissue Myofascial Release: Hip • Soft Tissue Myofascial Release: Trans­ • Soft Tissue Myofascial Release: Knee verse Diaphragms (all) • Muscle Energy Technique and 'Beyond' for Bilateral Lower Extremity joints. • Soft Tissue Myofascial Release: Hip, Ankle

122 ADVANCED STRAIN AND (DUNmmAIN • Muscle Energy Technique and 'Beyond' • Protective Muscle Spasm (Muscle Barriers); for Bilateral Lower Extremity Joints. Hip, Knee, Ankle 2. Chronic Stage (any time after 10 days • Myofascial Test: Shins post-op) Range of Physiologic Motion: Ankle Myofascial Release: • Mobility Testing: Tibiotalar, Subtalar, • Soft Tissue Myofascial Release: Transverse Tibiofibular Diaphragms • Soft Tissue Myofascial Release: Hip; Knee; • Foot Posture: Pronation, Supination Ankle Intrinsic Foot Muscle Spasm • Muscle Energy Technique and 'Beyond': for Bilateral Lower Extremity Joints. • Foot Posture 3. Protective Muscle Spasm: Strain and Coun­ Treatment terstrain: lIiacus; Medial Hamstrings; Ante­ rior 5th Lumbar; Abductors; Adductors; 1. Normalize ankle range of motion: manipu­ Quadriceps; Gastrocnemius. late tibiotalar and subtalar joints. Muscle Energy Technique and 'Beyond' for Bilateral 4. Repeat #3. Lower Extremity Joints. 5. Articular Fascial Release: Pelvic Joints; Hip 2. Eliminate protective muscle spasm: Strain Joint. and Counterstrain: especially lIiacus; Ham­ 6. Tendon Release TherapyO for Bilateral strings; Anterior and Posterior Cruciates; Quadriceps; Medial Gastrocnemious. Lower Extremity Joints-Hold for DeFacili­ rated Fascial Release. 3. Myofascial Release: 7. Restore Ankle Dorsiflexion: Mobilize Sub­ • Soft Tissue Myofascial Release to Knee. talar and Tibiotalar Joints (Do not place Articular Fascial Release: Knee Joint. forces on knee). Articular Fascial Release: Patellar 8. Ligament Fiber T herapyO for Bilateral Technique. Lower Extremity Joints. • Muscle Belly Technique: Quadriceps; 9. Orthotics and strengthening. Gastrocnemious. Chondromalacia 4. Patellofemoral Mobilization (if residual crepitus is significant): Home rental elec­ Eva/uatioll trical muscle stimulator, with electrode on the distal head of the Quadriceps Medialis. • Neurologic and Gait Use two times a day for 30 minute sessions. • Ranges of Physiologic Motions: Knee Rental 6 weeks (mild) to 3 months (severe • Mobility Testing of Accessory Movements: crepitus). Knee 5. Tendon Release T herapyO for Bilateral Ligamentous integrity Lower Extremity Joints-Hold for DeFacili­ • Meniscus Testing rated Fascial Release. • Patella Mobility Testing Apprehension/Grinding Test for Chondro­ 6. Ligament Fiber T herapyO for Bilateral malacia (crepitus: mild, moderate, severe) Lower Extremity Joints. • Manual Muscle Testing • Leg Muscle Length: Hamstrings, Quads, 7. Orthotics: Immediate fabrication of tem­ Gastrocnemious, Adductors, lIioribial Band porary orthotics to normalize forces tran­ scribed up the leg due to pronated or supinated feet. Fabrication of permanent orthotics after completion of manual ther­ apy protocol.

UPPER AND LOWER EXTREMITIES 123 8. Strengthening program: After elimination • Articular Fascial Release ro of all pain (4-6 weeks), give home exercise Tibiofemoral Joint. program ro srrengthen all pelvidhip/ and lower extremity musculature. Quadriceps 4. Normalize Ankle Range of Motion: Man­ should wait until completion of manual ipulate Tibiotalar and Subtalar Joints. therapy protocol. 5. Eliminate Foot and Ankle Protective Comments Muscle Spasm: Strain and Counterstrain: Medial Ankle; Medial Calcaneus (foot Four ro ten sessions may be needed ro normalize intrinsics). range of motion, eliminate muscle spasm, elimi­ nate pain and inflammation, and treat myofas­ 6. Specific Fascial Release Techniques: ciaI dysfunction. Patient may then be checked • Medial and Lateral Collateral ligaments every 3-4 weeks. • Patella Release • Muscle Belly Technique: Medial Ham­ Meniscus Dysfunction strings; Quadriceps; Gastrocnemius Evaluation 7. Tendon Release T herapyC for Bilateral Lower Extremity Joints-Hold for DeFacili­ • Neurologic and Gait tated Fascial Release. • Ranges of Physiologic Motions: Hip, Knee 8. Ligament Fiber T herapyC for Bilateral and Ankle Lower Extremity Joints • Mobility Testing of Accessory Movements: 9. Orthotics and strengthening. Hip, Knee, Patella, Ankle, Tibiofibular • Compression and Locking Tests for Menis­ Shin Splints cus; Drawer Tests Evaluation Manual Muscle Testing Leg Muscle Length: Hamstrings, Quadri­ • Neurologic and Gait ceps, Gastrocnemius, Adducrors, Iliotibial • Ranges of Physiologic Motions: Knee and Band Protective Muscle Spasm (Muscle Barriers): Ankle Iliacus; quadriceps; Adducrors; Abductors; • Mobility Testing of Accessory Movements: Medial Hamstrings; Gastrocnemius • Myofascial Testing: Around Knee Joint Knee, Ankle, and Tibiofibular Joints • Foot Posture: Pronation, Supination • Manual Muscle Testing • Protective Muscle Spasm (Muscle Barriers): Treatment Focus: Gastrocnemius and Tibialis Anterior 1. Muscle Energy Technique and 'Beyond' for • Myofascial Test: Shins Bilateral Lower Extremity Joints. • Intrinsic Foot muscle spasm 2. Eliminate protective muscle spasm: Strain Treatment and Counterstrain: Iliacus; Adducrors; Quadriceps; Gastrocnemius. 1. Normalize Ankle Range of Motion: Manip­ ulate Tibiotalar and Subtalar Joints 3. Myofascial Release: • Soft Tissue Myofascial Release ro Knee 2. Eliminate protective muscle spasm: Strain Joint and Counterstrain: Iliacus; Hamstrings; Abducrors; Iliotibial Band; Medial Gastroc­ nemius; Lateral Ankle; Lateral Calcaneus. 3. Myofascial Release: • Soft Tissue Myofascial Release ro Knee

124 ADVANCED IIiAIN AND CDUNTEiSTRAIN • Soft Tissue Myofascial Release to Ante­ 2. Eliminate protective muscle spasm: rior Compartment (shins) Strain and Counterstrain: Iliacus; Adduc­ Hanging Technique for Tibiofibular tors; Medial Hamstrings; Gastrocnemius. Joint 3. Myofascial Release: • Muscle Belly Technique for Peroneals Soft Tissue Myofascial Release just 4. Muscle Energy Technique and 'Beyond' for above site Scat Release to site of tendon tear Bilareral Lower Extremity Joints. (after healing) 5. Tendon Release TherapyD for Bilateral • Tendon Release to Insertion of Tendon Lower Extremity Joints-Hold for DeFacili­ on Calcaneus tated Fascial Release. 6. Ligament Fiber T herapyD for Bilateral • Muscle Belly Technique to Gastro­ Lower Extremity Joints. cnemIUS 7. Electrotherapy: Iontophoresis with lodex (Iodine Methyl Salicylate) to Anterior Com­ 4. Tendon Release TherapyD for Bilateral partment (J -4 sessions). Lower Extremity Joints-Hold for DeFa­ 8. Orrhotics: Assess feet for pronation/ cilitated Fascial Release. supination. 9. Strengthening program. 5. Normalize Ankle Range of Motion: Ma­ nipulate Tibiotalar and Subtalar Joints. Comnlellt 2 to 4 sessions IS sufficient for Shin Splints 6. Ligament Fiber TherapyD for Bilateral Protocol. Lower Extremity Joints. Achilles Tendon Tears 7. Orthotics and Strengthening. 8. Electrotherapy: Iontophoresis with lodex Eva/uation (Iodine Methyl Salicylate) to Anterior • Neurologic and Gait Compartment (1-4 sessions). • Ranges of Physiologic Motions: Knee and 9. OrthOtics: Assess feet for pronation! supll1anon. Ankle '10. Strengthening program. Mobility Testing of Accessory Movements: Knee, Ankle, and Tibiofibular Joints Commellt Manual Muscle Testing 2 to 4 sessions is sufficient for Shin Splints • Protective Muscle Spasm (Muscle Barriers): Protocol. Iliacus; Adductors; Medial Hamstrings; Quadriceps; Gastrocnemius Plantar Fasciitis Myofascial Testing: around Ankle Joint; Achilles Tendon; Calcaneal lnserrion; Gas­ Eva/uation trocnemius; Knee Joint (especially posterior • Neurologic and Gait aspect) • Ranges of Physiologic Motions: Ankle • Foot posture and Foot • Mobility Testing of Accessory Movements: Treatment Ankle and Foot Joints Manual Muscle Testing I . Muscle Energy Technique and 'Beyond' for • Protective Muscle Spasm (Muscle Barriers): Bilateral Lower Extremity Joints. focus on: Gastrocnemius; Intrinsic foot muscles

UPPER ANO lOWER EXTREMITIES 125 Myofascial Testing: Plantar fascia Treatment Foot Posture: Pronation/supination 1 . Eliminate (decrease) Hypertonicity: Strain Treatment and Counterstrain: 1. Mobilize Ankle Range of Motion: Man­ • All 7 Sacral Tender Points; Piriformis; Ante­ ipulate Tibiotalar and Subtalar Joints rior 5th Lumbar; Iliacus; Adductors; Medial Hamstrings; Quadriceps; Abductors; Gas­ 2. Muscle Energy Technique and 'Beyond' trocnemius; Medial Ankle; Medial Calca­ for Bilateral Lower Extremity Joints. neus; Lateral Ankle; Lateral Calcaneus (Talus for Club Foot & Pronated Foot). 3. Eliminate Protective Muscle Spasm: Strain and Counterstrain: Iliacus; Medial 2. Myofascial Release: Hamstrings; Gastrocnemius; Flexed • Soft Tissue Myofascial Release Tech­ Calcaneus. nique: Transverse Fascial Diaphragms (all); Hip; Knee; Ankle; Foot 4. Intrinsic Foot muscles: especially Extensors. Articular Fascial Release: Pelvic Joints; 5. Myofascial Release: Soft Tissue Myofascial Hip; Knee (Tibiofemoral); Ankle (Tibiotalar); Release to Plantar fascia. Specific Fascial Release Techniques: 6. Tendon Release T herapy\" for Bilateral Muscle Belly Technique for Medial Hamstrings; Quadriceps; Gastro­ Lower Extremity Joints-Hold for DeFacili­ cnemius tated Fascial Release. 7. Ligament Fiber Therapy\" for Bilateral 3. Muscle Energy Technique and 'Beyond' for Lower Extremity Joints. Bilateral Lower Extremity Joints. 8. Orthotics and Strengthening Intrinsics. 4. Tendon Release Therapy\" for Bilateral Spasticity of lower Quadrant Lower Extremity Joints-Hold for DeFacili­ rared Fascial Release. Evaluation S. Normalize Ankle Joint Range of Motion: • Neurologic: Focus on Spastic Synergic Pat­ Manipulate Tibiotalar and Subtalar Joints. tern which includes: elevated and retracted pelvis; flexed lumbar and hip; internally 6. Ligament Fiber Therapy\" for Bilateral rotated hip; flexed (occasionally extended) Lower Extremity Joints. knee; equinus (plantar flexed) or equino­ varus (plantar flexed and inverted) foot; 7. Repeat #1 and #2. and Gait 8. Orthotics. Ranges of Physiologic Motions: Lumbosacral region: Hip; Knee; Ankle. Cervical Syndrome • Mobility Testing of Accessory Joint Move­ Evaluatiol1 ments: LS/Sl ; Pelvic Joints; Hip Joint; Knee Joint; Ankle Joint • Posture: Sagittal, Coronal, Transverse planes: Total body; focus upper quadrant • Muscle Tone and Muscle Testing • Hypertonicity: Lumbar Flexors; Iliacus; • Neurologic: Focus upper quadrant • Ranges of Physiologic Motions: All upper Adductors; Abductors; Medial Hamstrings; quadriceps; Gastrocnemius quadrant joints • Myofascial Testing: Total Lower Quadrant • Mobility Testing of Accessory Movements: • Foot Posture All upper quadrant joints • Ligamentous Integrity

126 ADVANCED STRAIN AND COUNTERSTRAIN • Apprehension/Grinding Tests 8. Work Hardening. • Manual Muscle Testing • Protective Muscle Spasm (Muscle Barriers): Comments 1. A McKenzie PtOgram may be used to stabi­ Neck, Shoulder, Elbow, Forearm, Wrist, Fingers/Hand lize the cervical disc. • Myofascial Test: Glides; mapping 2. Occasionally, treatment of biomechanics for Treatment the pelvis and sacrum (Muscle Energy Tech­ nique and 'Beyond') is essential to maintain J. Muscle Energy Technique and 'Beyond' for cervical disc reduction. Bilateral Upper Extremity Joints. Rotator Cuff Syndrome 2. Eliminate Protective Muscle Spasm: StrainlCounterstrain: Evaluation • Anterior Thoracic (Anterior Tl to T4) Anterior Cervicals (especially Anterior • Posture: Sagittal, Coronal, Transverse C5: hold for De-Facilitated Fascial planes: tOtal body; Focus upper quadrant Release) Neurologic: Focus upper quadrant Lateral Cervicals (especially Lateral C5: Ranges of Physiologic Motions: Upper hold for De-Facilitated Fascial Release) quadrant, all upper quadrant joints Posterior Cervicals Elevated First Rib; Depressed Second • Mobility Testing of Accessory Movements: Rib; Depressed Third Rib; Rib All upper quadrant joints (PectOralis Minor); Latissimus Dorsi; Subscapularis; Anterior and Posterior • Ligamentous Integriry Acromioclavicular joints; Supraspina­ ApprehensiOn/Grinding Tests tus; Infraspinatus; Biceps. Manual Muscle Testing 3. Myofascial Release: • Protective Muscle Spasm (Muscle Barriers): Diaphragm Releases (especially Tho­ Neck, Shoulder, Elbow, Forearm, Wrist, racic Inlet) FingersIHand Myofascial Test: Glides; mapping • Sofr Tissue Myofascial Release: Clavipectoral Release; Lateral Neck Treatment Hold 1. Muscle Energy Technique and 'Beyond' Hyoid Release (4-phases) Articular Fascial Release: Glenohumeral for Bilateral Upper Extremity Joints. joint; Scapulothoracic joint 2. Eliminate Protective Muscle Spasm: 4. Tendon Release Therapy\" for Bilateral Strain/Counterstrain: Upper Extremity Joints-Hold for DeFacili­ • Anterior Thoracic (Anterior Tl to T4) tated Fascial Release • Anterior Cervicals (especially Anterior C5: hold for De-Facilitated Fascial 5. Ligament Fiber Therapy\" for Bilateral Release) Upper Extremity Joints. • Lateral Cervicals (especially Lateral C5: hold for De-Facilitated Fascial Release) 6. Strengthening PtOgram: especially upper Posterior Cervical quadrant. • Elevated First Rib; Depressed Second Rib; Depressed Third Rib; Rib (Pec­ 7. Posture Retraining: especially focus on for­ toralis Minor); Latissimus Dorsi; ward head and neck posture and protracted shoulders.

UPPER AND LOWER EXTREMITIES 127 Subscapularis; Anterior and Posterior Fingers/Hand Acromioclavicular joints; Supraspina- Myofascial Test: Glides, Mapping tus; Infraspinatus; Biceps. 3. Myofascial Release: Treatment • Diaphragm Releases (especially Tho- 1. Muscle Energy Technique and 'Beyond' racie Inlet) • Soft Tissue Myofascial Release: for Bilateral Upper Extremity Joints. Clavipecroral Release; Lateral Neck 2. Eliminate Protective Muscle Spasm: Hold • Hyoid Release (4-phases) Strain/Counterstrain: • Articular Fascial Release: Glenohumeral • Anterior Thoracic (Anterior Tl ro T4) joint; Scapulothoracic joint • Anterior Cervicals (especially Anterior • Specific Myofascial Release Techniques: C5: hold for De-Facilitated Fascial Tendon Releases of Rotaror Cuff Ten- Release) dons; Capsular Release of • Lateral Cervicals (especially Lateral C5: Glenohumeral Joint Capsule hold for De-Facilitated Fascial Release) 4. Tendon Release TherapyO for Bilateral • Posterior CervicaIs Upper Extremity Joints-Hold for DeFacili- • Elevated First Rib; Depressed Second tated Fascial Release. Rib; Depressed T hird Rib; Rib (Pec- 5. Ligament Fiber TherapyO for Bilateral roralis Minor); Latissimus Dorsi; Upper Extremity Joints. Subscapularis; Anterior and Posterior 6. Strengthening Program: especially upper Acromioclavicular joints; Supraspina- quadrant. tus; Infraspinatus; Biceps; Radial Head; 7. Posture Retraining: especially focus on for- Medial Epicondyle ward head and neck posture and protracted shoulders. 3. Myofascial Release: 8. Stabilization of Upper Quadrant. • Diaphragm Releases (especially Tho- racic Inlet) Bicipital Tendinitis • Soft Tissue Myofascial Release: Clavipecroral Release; Lateral Neck Evaluation Hold; Biceps; Elbow • Hyoid Release (4-phases) • Posture: Sagittal, Coronal, Transverse • Articular Fascial Release: Glenohumeral planes: rotal body; focus upper quadrant joint; Scapulothoracic joint • Specific Myofascial Release Techniques: • Neurologic: Focus upper quadrant Muscle Belly Release of Biceps; Tendon • Ranges of Physiologic Motions: Upper Release of Long Head of Biceps quadrant, all upper quadrant joints 4. Tendon Release TherapyO for Bilateral Mobility Testing of Accessory Movements: Upper Extremity Joints-Hold for DeFacili- All upper quadrant joints tated Fascial Release. • Ligamentous Integrity • Apprehension/Grinding Tests 5. Ligament Fiber T herapyO for Bilateral • Manual Muscle Testing Upper Extremity Joints. Protective Muscle Spasm (Muscle Barriers): Neck, Shoulder, Elbow, Forearm, Wrist, 6. Strengthening Program: especially upper quadrant. 7. Posture Retraining: especially focus on for- ward head and neck posture and protracted shoulders.

128 ADVAN(ED ITRAIN AND (DUNTERITRAIN SupraSpinatus Tendinitis Calcification • Articular Fascial Release: Glenohumeral joint; Scapulothoracic joint Evaluation Specific Myofascial Release Techniques: Tendon Release of Supraspinatus • Posture: Sagittal, Coronal, Transverse Tendon planes: total body; focus upper quadrant 4. Tendon Release TherapyC for Bilateral • Neurologic: focus upper quadrant Upper Extremity Joints-Hold for Defacili­ Ranges of Physiologic Motions: upper tated Fascial Release. quadrant, all upper quadrant joints Mobility Testing of Accessory Movements: 5. Ligament Fiber T herapyC for Bilateral all upper quadrant joints Upper Extremity Joints. Ligamentous Integrity Apprehension/Grinding Tests 6. Iontophoresis: Acetic Acid (positive elec­ Manual Muscle Testing trode on supraspinatus tendon). Protective Muscle Spasm (Muscle Barriers): Neck, Shouldet, Elbow, Forearm, Wrist, 7. Strengthening Program: Especially upper FingersfHand quadrant. Myofascial Test: Glides, Mapping 8. Posture Retraining: Especially focus on for­ Treatment ward head and neck posture and protracted 1. Muscle Energy Technique and 'Beyond' fot shoulders. Bilateral Upper Extremiry Joints. Dysphagia 2. Eliminate Protective Muscle Spasm: Evaluation Strain/Countersttain: • Anterior Thoracic (Anterior Tl to T4) • Posture: Sagittal, Coronal, Transvetse • Anterior Cervicals (especially Anterior planes: total body; focus upper quadrant cs: hold for De-Facilitated Fascial Release) • Neurologic: Focus upper quadrant • Lateral Cervicals (especially Lateral CS: • Ranges of Physiologic Motions: Upper hold for De-Facilitated Fascial Release) • Posterior Cervicals quadrant, All upper quadrant joints Elevated First Rib; Depressed Second • Mobility Testing of Accessory Movements: Rib; Depressed Third Rib; Rib (Pec­ toralis Minor); Latissimus Dorsi; All upper quadrant joints Subscapulatis; Anterior and Posterior • Ligamentous Integrity Acromioclavicular joints; Supraspin­ • Apprehension/Grinding Tests atus; Infraspinatus; Biceps Manual Muscle Testing 3. Myofascial Release: Protective Muscle Spasm (Muscle Barriers): • Diaphragm Releases (especially Tho­ Neck, Shoulder, Elbow, Forearm, Wrist, racic Inlet) FingersfHand Soft Tissue Myofascial Release: • Myofascial Test: Glides, Mapping Clavipectoral Release; Lateral Neck Hold Treatment • Hyoid Release (4-phases) 1. Muscle Energy Technique and 'Beyond' for Bilateral Upper Extremiry Joints. 2. Eliminate Protective Muscle Spasm: Strain/Counterstrain: • Anterior Thoracic (Anterior Tl to T4)

UPPER AND LOWER EXTREMITIES 129 Anterior Cervicals (especially Anterior • Neurologic: Focus upper quadrant CS: hold for De-Facilitated Fascial • Ranges of Physiologic Morions: All upper Release) Lateral Cervicals (especially Lateral CS: quadrant joints hold for De-Facilitated Fascial Release) • Mobility Tesring of Accessory Movements: Posterior Cervicals Elevated First Rib; Depressed Second all upper quadrant joints Rib; Depressed Third Rib; Rib (Pec­ • Ligamentous Integrity toralis Minor); Latissimus Dorsi; • Apprehension/Grinding Tests Subscapularis; Anterior and Posterior • Manual Muscle Testing Acromioclavicular joints; Supraspina­ tus; Infraspinatus; Biceps Protective Muscle Spasm (Muscle Barriers): • Do every Anterior Cervical Technique Neck, Shoulder, Elbow, Forearm, Wrist, and perform De-facilitated Fascial FingerslHand Release for each • Myofascial Test: Glides, Mapping 3. Myofascial Release: • Diaphragm Releases (especially Thoracic Treatmellt Inlet) Soft Tissue Myofascial Release: Clavipec­ 1. Muscle Energy Technique and 'Beyond' toral Release; Lareral Neck Hold for Bilateral Upper Extremity Joints. Hyoid Release (4-phases) 4. Tendon Release TherapyC for Bilateral 2. Eliminare Protective Muscle Spasm: Upper Extremity Joints-Hold for DeFacili­ Strain/Counterstrain: tared Fascial Release. • Anterior Thoracic (Anterior Tl to T4) S. Ligament Fiber TherapyQ for Bilateral • Anterior Cervicals (especially Anterior Upper Exrremiry Joints. CS: hold for De-Facilirated Fascial 6. Myofunctional Therapy: Strengthening and Release) Proprioception/Exteroception/Coordinarion • Lareral Cervicals (especially Lateral CS: of Hyoid System (references: Dan Garliner hold for De-Facilitared Fascial Release) Myo(unctional Therapy; Rocabado \"Six by • Posrerior Cervicals Six\" protocol). • Elevared First Rib; Depressed Second 7. Strengthening Program: Especially upper Rib; Depressed Third Rib; Rib (Pec­ quadrant. toralis Minor); Latissimus Dorsi; 8. Posrure Rerraining: Especially focus on for­ Subscapularis; Anterior and Posterior ward head and neck posture and protracted Acromioclavicular joints; Supraspina­ shoulders. tus; Lnfraspinarus; Biceps. Protrocted Shoulder Girdle 3. Myofascial Release: • Diaphragm Releases (especially Tho­ Evaluation racic Inlet) Sofr Tissue Myofascial Release: Posrure: Sagittal, Coronal, Transverse Clavipectoral Release; Lateral Neck planes: roral body; focus upper quadrant Hold Hyoid Release (4-phases) • Articular Fascial Release: Glenohumeral joint; Scapulothoracic joint 4. Tendon Release TherapyC for Bilateral Upper Extremity Joints-Hold for DeFacili­ rared Fascial Release.

130 ADVANCED STRAIN AND COUNTERSTRAIN 5. Ligament Fiber TherapyC for Bilateral tus; Infraspinatus; Biceps; Radial Head; Upper Extremity Joints. Anterior Carpals 3. Myofascial Release: 6. Strengthening Program: Especially upper • Diaphragm Releases (especially Tho­ quadrant. racic Inlet) • Soft Tissue Myofascial Release: 7. Posture Retraining: Especially focus on for­ Clavipectoral Release; Lateral Neck ward head and neck posture and protracted Hold; Elbow; Anterior Compartment; shoulders. Carpal Tunnel • Hyoid Release (4-phases) Tennis Elbow • Articular Fascial Release: Glenohumeral joint; Scapulothoracic joint; all Elbow Evaluation joints; Wrist joint. • Posture: Sagittal, Coronal, Transverse • Specific Myofascial Release Techniques: planes: rotal body; focus upper quadrant Muscle Belly Technique for Biceps and • Neurologic: Focus upper quadrant Triceps together, Brachioradialis; Ten­ • Ranges of Physiologic Motions: All upper don Release for Brachioradialis Tendon; quadrant joints Ligament Release for Lateral Ligaments Mobility Testing of Accessory Movements: of Elbow joint; Radiulnar Hanging All upper quadrant joints Technique. Ligamentous Integrity 4. Tendon Release T herapyC for Bilateral Apprehension/Grinding Tests Upper Extremity Joints-Hold for DeFacili­ • Manual Muscle Testing tated Fascial Release. • Protective Muscle Spasm (Muscle Barriers): 5. Ligament Fiber TherapyC for Bilateral Neck, Shoulder, Elbow, Forearm, Wrist, Upper Extremity Joints. FingerslHand 6. Iontophoresis: Iodex: Iodine Methyl Salicy­ • Myofascial Test: Glides, Mapping late (negative electrode) and Acetic Acid (positive electrode) to Brachioradialis Ten­ Treatment don. 7. Strengthening Program: Especially upper 1. Muscle Energy Technique and 'Beyond' for quadrant. Bilateral Upper Extremity Joints. 8. Posture Retraining: Especially focus on for­ ward head and neck posture and protracted 2. Eliminate Protective Muscle Spasm: shoulders. Strain/Counterstrain: Anterior Thoracic (Anterior Tl to T4) Golfer's Elbow Anteriot Cetvicals (especially Anterior CS: hold for De-Facilitated Fascial Evaluation Release) • Lateral Cervicals (especially Lateral CS: • Posture: Sagittal, Coronal, Transverse hold for De-Facilitated Fascial Release) planes: total body; focus upper quadrant • Posterior Cervicals • Elevated First Rib; Depressed Second • Neutologic: Focus upper quadrant Rib; Depressed T hird Rib; Rib (Pec­ • Ranges of Physiologic Motions: All upper roralis Minor); Latissimus Dorsi; Subscapularis; Anterior and Posterior quadrant joints Acromioclavicular joints; Supraspina-

UPPER AND LDWER EXTREMITIES 13 1 • Mobility Testing of Accessory Movements: Lateral Ligaments of Elbow joint; All upper quadrant joints Radioulnar Hanging Technique 4. Tendon Release T herapyC> for Bilateral • Ligamentous Integrity Upper Extremity Joints-Hold for DeFacili­ Apprehension/Grinding Tests tated Fascial Release. S. Ligament Fiber T herapyC> for Bilateral • Manual Muscle Testing Upper Extremity Joints. • Protective Muscle Spasm (Muscle Barriers): 6. Strengthening Program: Especially upper quadrant. Neck, Shoulder, Elbow, Forearm, Wrist, 7. Posture Retraining: Especially focus on for­ FingerslHand ward head and neck posture and protracted • Myofascial Test: Glides, Mapping shoulders. Treatment Anterior Comportment Syndrome 1. Muscle Energy Technique and 'Beyond' Evaluation for Bilateral Upper Extremity Joints. Posture: Sagittal, Coronal, Transverse 2. Eliminate Protective Muscle Spasm: planes: total body; focus upper quadrant Strain/Counterstrain: • Neurologic: Focus upper quadrant • Anterior Thoracic (Anterior Tl to T4) • Ranges of Physiologic Motions: All upper • Anterior Cervicals (especially Anterior quadrant joints CS: hold for De-Facilitated Fascial • Mobility Testing of Accessory Movements: Release) All upper quadrant joints • Lateral Cervicals (especially Lateral Ligamentous Integrity CS: hold for De-Facilitated Fascial • Apprehension/Grinding Tests Release) • Manual Muscle Testing • Posterior Cervicals • Protective Muscle Spasm (Muscle Barriers): • Elevated First Rib; Depressed Second Neck, Shoulder, Elbow, Forearm, Wrist, Rib; Depressed Third Rib; Rib (Pec­ Fingers/Hand toralis Minor); Latissimus Dorsi; Myofascial Test: Glides, Mapping Subscapularis; Anterior and Posterior Acromioclavicular joints; Supraspina­ Treatment tus; Infraspinatus; Biceps; Radial Head; 1. Muscle Energy Technique and 'Beyond' for Medial Epicondyle; Anterior Carpals Bilateral Upper Extremity Joints. 3. Myofascial Release: 2. Eliminate Protective Muscle Spasm: • Diaphragm Releases (especially Tho­ racic Inlet) Strain/Counterstrain: • Soft Tissue Myofascial Release: • Anterior Thoracic (Anterior Tl to T4) Clavipectoral Release; Lateral Neck • Anterior Cervicals (especially Anterior Hold; Elbow; Anterior Compartment; CS: hold for De-Facilirated Fascial Carpal Tunnel Release) Hyoid Release (4-phases) • Lateral Cervicals (especially Lateral CS: Articular Fascial Release: Glenohumeral hold for De-Facilitated Fascial Release) joint; Scapulothoracic joint; all Elbow Posterior Cervicals joints; Wrist joint • Specific Myofascial Release Techniques: Muscle Belly Technique for Biceps and Triceps together; Ligament Release for

132 ADVANCED ITRAIN AND (DUNTERITRAIN Elevated First Rib; Depressed Second Mobility Testing of Accessory Movements: Rib; Depressed Third Rib; Rib (Pec­ All upper quadrant joints toralis Minor); Latissimus Dorsi; Ligamentous Integrity Subscapularis; Anterior and Posterior Apprehension/Grinding Tests Acromioclavicular joints; Supraspina­ Manual Muscle Testing tus; Infraspinatus; Biceps; Radial Head; Protective Muscle Spasm (Muscle Barriers): Anterior Carpals Neck, Shoulder, Elbow, Forearm, Wrist, 3. Myofascial Release: Fingers/Hand • Diaphragm Releases (especially Tho­ • Myofascial Test: Glides, Mapping racic Inlet); Soft Tissue Myofascial Release: Treatment C1avipectoral Release; Lateral Neck Hold; Elbow; Anterior Compartment; l. Muscle Energy Technique and 'Beyond' for Carpal Tunnel Bilatetal Upper Extremity Joints. Hyoid Release (4-phases) Articular Fascial Release: Glenohumeral 2. Eliminate Protective Muscle Spasm: joint; Scapulothoracic joint; all Elbow Strain/Counterstrain: joints; Wrist joint Anterior Thoracic (Anterior Tl to T4) • Specific Myofascial Release Techniques: Anterior Cervicals (especially Anterior Muscle Belly Technique for Biceps and CS: hold for De-Facilitated Fascial Triceps together; Ligament Release for Release) Lateral Ligaments of Elbow joint; Radi­ Lateral Cervicals (especially Lateral C5: ulnar Hanging Technique hold for De-Facilitated Fascial Release) 4. Tendon Release T herapyC for Bilateral Posterior Cervicals Upper Extremity Joints-Hold for DeFacili­ • Elevated First Rib; Depressed Second tated Fascial Release. Rib; Depressed Third Rib; Rib (Pec­ 5. Ligament Fiber T herapyC for Bilateral toralis Minor); Latissimus Dorsi; Upper Extremity Joints. Subscapularis; Anterior and Posterior 6. Strengthening Program: Especially upper Acromioclavicular joints; Supraspina­ quadrant. tus; Infraspinatus; Biceps; Radial Head; 7. Posture Retraining: Especially focus on for­ Anterior Carpals; Posterior Carpals ward head and neck posture and protracted shoulders. 3. Myofascial Release: • Diaphragm Releases (especially Tho­ Carpal Tunnel Syndrome racic Lnlet) • Soft Tissue Myofascial Release: Evaluation Clavipectoral Release; Lateral Neck Hold; Elbow; Anterior Compartment; Posture: Sagittal, Coronal, Transverse Carpal Tunnel planes: toral body; focus upper quadrant • Hyoid Release (4-phases) • Neurologic: Focus upper quadrant • Articular Fascial Release: Glenohumeral • Ranges of Physiologic Motions: All upper joint; Scapulorhoracic joint; all Elbow quadrant joints joints; Wrist joint • Specific Myofascial Release Techniques: Tendon Release: Anterior and Posterior Tendons crossing Wrist joint; Retinacu­ lum Technique

UPPER AND lDWER EXTREMITIES 133 4. Tendon Release Therapy\" for Bilateral toralis Minor); Latissimus Dorsi; Upper Extremity joints-Hold for DeFacili­ Subscapularis; Anterior and Posterior tated Fascial Release. Acromioclavicular joints; Supraspina­ tus; Infraspinatus; Biceps; Radial Head; S. Ligament Fiber T herapyC> for Bilateral Anterior Carpals; Posterior Carpals; Upper Extremity joints First Carpometacarpal Technique 3. Myofascial Release: 6. Strengthening Program: Especially upper • Diaphragm Releases (especially Tho­ quadrant. racic Inlet) • Soft Tissue Myofascial Release: 7. Posture Retraining: Especially focus on for­ Clavipectoral Release; Lateral Neck ward head and neck posture and protracted Hold; Elbow; Anterior Compartment; shoulders. Carpal Tunnel • Hyoid Release (4-phases) De Quervain's Syndrome • Articular Fascial Release: Glenohumeral joint; Scapulothoracic joint; all Elbow Evaluation joints; Wrist joint; First Carpomeracarpal joint Posture: Sagittal, Coronal, Transverse • Specific Myofascial Release Techniques: planes: Toral body; focus upper quadrant Tendon Release: Abductor and Adduc­ Neurologic: Focus upper quadrant tor Thumb tendons • Ranges of Physiologic Motions: All upper 4. Tendon Release TherapyC> for Bilateral quadrant joints Upper Extremity joints-Hold for DeFacili­ Mobility Testing of Accessory Movements: tated Fascial Release. All upper quadrant joints 5. Ligament Fiber T herapyC> for Bilateral Ligamentous Integrity Upper Extremity joints. • Apprehension/Grinding Tests 6. Strengthening Program: Especially upper • Manual Muscle Tesring quadrant. • Protective Muscle Spasm (Muscle Barriers): 7. Posture Retraining: Especially focus on for­ Neck, Shoulder, Elbow, Forearm, Wrist, ward head and neck posture and protracted Fingers/Hand shoulders. • Myofascial Test: Glides, Mapping 8. Hand Funcrional T herapy. Treatment Spasticity of the Upper Extremity 1. Muscle Energy Technique and 'Beyond' Evaluation for Bilateral Upper Extremity joints. Posture: Sagittal, Coronal, Transverse 2. Eliminate Protective Muscle Spasm: planes: toral body; focus upper quadrant Srrain/Counrerstrain: • Neurologic: Focus upper quadrant, focus • Anterior Thoracic (Anterior T1 to T4) on Spastic Synergic Pattern which includes: Anterior Cervicals (especially Anterior flexed Cervical Spine; elevared and CS: hold for De-Facilitated Fascial protracted Shoulder Girdle; flexed, Release) adducted and internally rotared Shoulder • Lateral Cervicals (especially Lateral CS: hold for De-Facilitated Fascial Release) Posrerior Cervicals Elevated First Rib; Depressed Second Rib; Depressed Third Rib; Rib (Pec-

134 ADVANCED STRAIN AND CDUNTERSTRAIN joint (assess for Anterior and Caudal sub­ tus; Infraspinatus; Biceps; Radial Head; luxed Hemiplegic Shoulder; flexed Elbow; Anrerior Carpals; Posterior Carpals; pronated Forearm; flexed and ulnar devi­ First Carpometacarpal Technique; ated Wrist; flexed and adducted Thumb; Inrerosseous muscles. flexed Fingers); 2. Myofascial Release: • Ranges of Physiologic Motions: All upper • Diaphragm Releases (especially Tho­ quadrant joints racic Inlet) • Mobility Testing of Accessory Movements: • Soft Tissue Myofascial Release: All upper quadrant joints Clavipecroral Release; Lateral Neck • Ligamentous Integrity Hold; Elbow; Anrerior Comparrment; • Apprehension/Grinding Tests Carpal Tunnel • Manual Muscle Testing • Hyoid Release (4-phases) • Hyperronicity: Cervical flexors; Supraspina­ • Arricular Fascial Release: Glenohumeral rus; Pectoralis Minor; Latissimus Dorsi; joinr; Scapulorhoracic joinr; all Elbow Subscapularis; Biceps; and all Flexors. joints; Wrist joinr; First • Myofascial Test: Glides, Mapping Carpometacarpal joinr • Specific Myofascial Release Techniques: Treatment Tendon Release: Abductor and Adduc­ 1. Eliminate Protective Muscle Spasm: ror T humb tendons 3. Muscle Energy Technique and 'Beyond' StrainiCounrerstrain: for Bilateral Upper Extremity Joinrs. • Anrerior Thoracic (Anterior Tl ro T4) 4. Tendon Release T herapy\" for Bilatetal • Anrerior Cervicals (especially Anrerior Upper Extremity Joints-Hold for DeFacili­ CS: hold for DeFacilitated Fascial tated Fascial Release. Release) 5. Ligament Fiber Therapy\" for Bilateral • Lateral Cervicals (especially Lateral CS: Upper Extremity Joinrs. hold for De-Facilitated Fascial Release) 6. Strengthening Program: Especially upper • Posterior Cervicals quadranr. • Elevated First Rib; Depressed Second 7. Posture Retraining: Especially focus on for­ Rib; Depressed Third Rib; Rib (Pec­ ward head and neck posture and protracted roralis Minor); Latissimus Dorsi; shoulders. Subscapularis; Anrerior and Posteriot 8. Hand Functional Therapy. Acromioclavicular joints; Supraspina-

CHAPTER 14 PRESSURE SENSOR THERAPY© OF THE FOOT AND ANKLE COMPLEX The following is a new avenue of therapy appro­ there are often pressure related restrictIOns. priate for clients with severe postural deviations When the foot hits the ground, there is a pres­ of the feet. Included in the recommended pro­ sure resistance within the foot and ankle com­ gram for therapy are the following: plex which forces the foot into a resistance mode. This resistance mode allows the ground StrainiCounrerstrain to decrease protective forces to \"pressurize\" (adapt internal pressures) muscle spasm and spasticity affecting tone during transcription of forces up the leg. The re­ and posture of the foot. sistance mode is required for balance. Wei­ • Myofascial Release to decrease fascial dys­ selfish-Giammarreo discovered pressure sensors, function of the foot, especially the plantar and learned that these pressure sensors within fascia. the foot and ankle complex are often compro­ Muscle Energy and 'Beyond' Technique for mised secondary to trauma, tissue damage, and the pelvis to improve balance and weight poor postural alignment. bearing, and for the sacrum to normalize innervation to the foot and ankle, via allevi­ locotion of Pressure Sensors of Foot ation of sacral plexus tension. • Muscle Energy and 'Beyond' Technique for Location of these pressure sensors within the the tibiotalar joint. foot and ankle complex are found specifically at • Tendon Release T herapy\", especially for the the following places: Achilles Tendon, Peroneal Tendons, and Toe Tendons. Anterior to the lateral malleolus and 1 mm • Ligament Fiber T herapy\". caudal. • Visceral mobilization to decrease any fascial Posterior to the medial malleolus and 3 mm restrictions of the pelvic and abdominal caudal. region which may be affecting the fascial • Five (5) mm distal to each of the three elongation of the leg, foot and ankle. cuneiforms, distal from their distal articular Neural Tissue Tension Technique to surfaces, exactly midline (medial/lateral decrease all fascial restrictions of: The dura midline) of each cuneiform, on the dorsal mater and dural sheaths; the peripheral surface. nerves including sciatic, tibial, common • Two (2) mm superior to the proximal artic­ peroneal; and to address any spinal cord ular surface of the first metatarsal head on fibrosis. the dorsal surface. Advanced Strain and Counterstrain Tech­ • Lateral to the proximal head of the fifth nique to address circulation problems of the metatarsal, on the very lateral surface. extremity. These 7 pressure sensors resist forces tran­ Beyond the fascial, circulatory, bony, articu­ scribed up the leg during weight bearing. The lar, muscle, tendinous and ligamentous restric­ resultant resistance is the balance of the foot­ tions which may be affecting the foot and ankle, ground forces. 135

136 ADVANCED ITRAIN AND (DUNTERITRAIN loterol view of two pressure sensor of foot (one is anterior and one (I) mm inferior 10 folerol molleolus); on. is lolerol lo Ihe proximol heod of Ihe fihh melolorsol). Dorsal ,iew of four pressure senso� of fool (IDr.. are eoch live (5) mm distal 10 eoch cuneiform, midline; one is Iw<> (2) mm superior 10 proximal fi�1 melalorsal head). Medial ,iew of on. pressure sensor of fool (poslerior and Ihr.. (3) mm \"udal 10 medial malleolus).

UPPER AND LOWER EXTREMITIES 137 Fool Pressure Therapy(Q Step 2 Treatment of the lower extremity for balance Perform Neurofascial Processo: Connect each utilizing these pressure sensors is as follows: pressure sensor of the foorlankle complex to the Heart pressure sensor which is located at the an­ Step 1 terior/inferior heart. Perform a 3-planar fascial fulcrum Soft Tissue Myofascial Release Technique (Chapter 10) with the pressure sensors between the 2 hands to eliminate fascial restrictions surrounding the sensors. Soh TISSUe MyollJS(iol R,I.... T\"hniqu\" 0 3·plonor 'lJS(i.l luluum 'pproa,h, over cuneiform !'fISsure sensors.. Conn,d Ih. pressure sensors 01 the loat {<uneilorm pressure se\"\",,1 with the inlerior \"Ped 01 the heart ond woit lor the \"R,I,ase:

138 ADVANCED STRAIN AND CDUNTERSTRAIN Step 3 Step 4 Perform Neurofascial Processo: Connect each Perform Neurofascial Processo: Connect the pressure sensor ro the low back (ureters) ro elim­ pressure sensors ro: inate any toxicity which may be affecting the pressure ensors. • Sacrum T 1 2/U C7ITJ OIA and the transverse sinus (onnect the pressure senso� of the foot (cuneiform pressure sensors) 10 the low back and wail for Ih. \"R.f..,,: (onned the cuneiform pressure sensors with sacrum and wail for the �Releose\"

UPPER AND LOWER EXTREMITIES 139 (onned the cun.iform pressure \"nso� with Tl2/l1 ond woijfor the 'R.I.\",: Conned the cuneiform j>fessure sensors with the O/A and transverse sinus and w,ij for the 'Release: (onn.ct the cuneiform prellor \"n\\O� with a/II ond woij for the 'R.I.\",:

140 ADVANCED ITRAtN AND COUNHRITRAtN Step 5 Perform Neurofascial Processo: Connect each pressure sensor to: Pubidsuprapubic regions Xiphoid region including lower rib cage and infra-costal tissue • Anterior thoracic outlet (onned the ,\"neilorm pressure senso\" with the low �ernum ond rib \"g, ond wuitlor the \"R.lease: (onnecl lhe cuneiform pressure sensors wilh the pubic region and wail for the \"Release.\" Conned the cuneiform pressure sensors with the anterior thoracic outlet and wo� lor the \"Release: